What can I do to relieve itchy heels?

Treatment of Itchy Heels

For itchy heels, start with topical terbinafine 1% cream applied once daily for 1 week, as this is the most effective first-line treatment for tinea pedis (athlete's foot), which is the most common cause of isolated heel itching. 1

Initial Diagnostic Approach

The most likely diagnosis is tinea pedis, which presents as a scaly or vesiculopustular eruption that is often itchy and can involve all areas of the foot, including the heels. 1 The predominant causative organisms are Trichophyton rubrum and Trichophyton mentagrophytes. 1

First-Line Topical Treatment

Apply terbinafine 1% cream once daily for 1 week to the affected heel areas. 1 This regimen achieves approximately 94% mycological cure rates and offers the advantage of once-daily dosing with briefer treatment duration compared to other topical options. 1

Alternative Topical Options if Terbinafine is Unavailable:

• Ciclopirox olamine 0.77% cream or gel applied twice daily for 4 weeks achieves approximately 60% cure at end of treatment and 85% cure two weeks after treatment. 1
• Clotrimazole 1% cream applied twice daily for 4 weeks is less effective but available over-the-counter. 1

Essential Adjunctive Measures

These measures are critical to prevent recurrence and enhance treatment success:

• Apply foot powder after bathing, which reduces recurrence rates from 8.5% to 2.1%. 1
• Thoroughly dry between the toes after showers to eliminate the warm, humid environment that promotes fungal growth. 1
• Change socks daily and wear clean, dry socks. 1
• Periodically clean athletic footwear to eliminate fungal reservoirs. 1

When to Escalate to Oral Therapy

If topical treatment fails after 4 weeks, consider oral terbinafine 250 mg once daily for 1 week, which has similar mycological efficacy to 4 weeks of topical clotrimazole but with faster clinical resolution. 1 This oral regimen may have a slightly lower relapse rate compared to oral itraconazole. 1

Alternative Diagnosis: Non-Fungal Causes

If the itching does not respond to antifungal therapy within 2-4 weeks, consider:

• Atopic dermatitis or eczema: Apply hydrocortisone 1% cream 3-4 times daily to affected areas, which is FDA-approved for itching, inflammation, and rashes in patients 2 years and older. 2, 3 This should be combined with liberal application of emollients to maintain skin barrier function. 1, 2
• Contact dermatitis: Treat similarly with hydrocortisone 1% cream and emollients. 2

Symptomatic Relief for Itching

Regardless of the underlying cause:

• Apply emollients liberally and frequently to all affected areas, as this forms the foundation of treatment for any pruritic rash. 1, 2
• Consider a non-sedating antihistamine such as loratadine 10 mg daily, cetirizine 10 mg daily, or fexofenadine 180 mg daily for daytime antipruritic relief. 2
• For nighttime pruritus, diphenhydramine 25-50 mg at bedtime may be used due to its sedative properties. 2

Common Pitfalls to Avoid

• Do not assume treatment failure is due to drug resistance alone—poor compliance, inadequate drug penetration, bacterial superinfection, or reinfection from contaminated footwear are more common causes. 4
• Do not treat the feet in isolation—examine for concomitant onychomycosis (nail infection), as this serves as a reservoir for reinfection and is present in up to 25% of cases. 4
• Avoid hot showers and excessive soap use, which can worsen skin dryness and itching. 2

When to Refer

If symptoms persist beyond 2-4 weeks despite appropriate treatment, consider dermatology referral for:

• Fungal culture to confirm diagnosis and guide therapy 4
• Evaluation for alternative diagnoses such as psoriasis, neuropathic itch, or other dermatoses 1
• Assessment for onychomycosis requiring systemic therapy 4